Africa: AIDS Optimism

Editor's Note

"[Four years ago] people like me were sick and tired, already, of
defeatist arguments [about AIDS], which had gone on way too long
already. To ask doctors, nurses, and other providers to give up on
treating the sick because they're too poor to pay was never, ever
acceptable to my co-workers in the field....We're still arguing,
it's true, but we're not arguing about the same things. Instead of
arguing whether or not to treat the poor who suffer from AIDS, or
drug-resistant tuberculosis, or even drug- resistant malaria, we're
arguing about what drugs should be used to treat these diseases." -
Paul Farmer, November 2005

In 2003, the World Health Organization set the goal of having 3
million people on AIDS treatment by the end of 2005. New programs
and funding from all sources led to over 1 million people on
treatment by the end of the year, with an estimated 250,000 to
500,000 lives saved. In Africa, approximately 200,000 more people
are receiving treatment every six months. But that still leaves
more than 5 million people in need of AIDS treatment, most of them
in Africa.

This AfricaFocus Bulletin contains excerpts from "The Case for
Optimism," a speech by Paul Farmer to the Time Global Health Summit
in November 2005. Farmer argues that notwithstanding the failure to
achieve the targets, the demonstrated advances point a clear road
ahead. The full text of the speech, and other information from the
conference, is available athttp://www.time.com/time/2005/globalhealth/transcripts.html

Another Bulletin sent out today contains reports on the latest AIDS
statistics released in South Africa. For earlier AfricaFocus
Bulletins on health issues, visithttp://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

The Case for Optimism

I am seldom invited to be the upbeat speaker at conferences of this
sort. Or of any sort, now that I think of it. But when I was asked
to address the case for optimism in our struggle to improve the
health of the world's poorest, I couldn't in good conscience
refuse. There are reasons for hope. ....

Let's look back to the year 2001, not too long ago. In 2001, if we
were meeting in New York to discuss these same topics, we would be
arguing. And the argument would have been about whether or not it's
even worth bothering to try to treat AIDS, for example, among poor
people in places like Haiti or most of Africa. The drugs alone then
cost thousands of dollars per patient per year. At the time there
was no such thing as the Global Fund to Fight AIDS, Tuberculosis,
and Malaria; and PEPFAR, the U.S. AIDS initiative, wasn't even a
twinkle in the president's eye. ... people like me were sick and
tired, already, of defeatist arguments, which had gone on way too
long already. To ask doctors, nurses, and other providers to give
up on treating the sick because they're too poor to pay was never,
ever acceptable to my co-workers in the field.

Now it's November 2005. The Gates Foundation performed CPR on
international health and the patient lived. The Global Fund and
PEPFAR have kept the patient stable enough to move out of the ICU.
We're still arguing, it's true, but we're not arguing about the
same things. Instead of arguing whether or not to treat the poor
who suffer from AIDS, or drug-resistant tuberculosis, or even drugresistant
malaria (the most common kind in Africa and much of
Asia), we're arguing about what drugs should be used to treat these
diseases. AIDS drug prices have fallen rapidly, from an average
wholesale price in 2001 of over $10,000 per patient per year to as
low as $130 per patient per year today. ...Anyone who thinks these
are not better, more interesting, more valuable discussions than
the old ones does not have to face, on a regular basis, the
destitute sick. We've come a long way in four years.

But not far enough. When we finally receive orders from on high to
roll-out proper treatment plans for difficult-to-treat diseases,
this is a good thing. But policy makers need to understand that
changing the mantra from "No, you can't fix this" to "OK, now do
the right thing" does not lead immediately to quality health care
for the world's bottom billion. Would that it were so easy. It's
impossible to reverse decades of neglect in the space of a few
years by saying a magic word. And the results of these past few
decades of neglect are not equivalent to those that preceded them;
they're worse. ...

But over twenty years of work in this arena has convinced me that
the only way to embrace a realistic optimism is to dispense with a
series of myths and mystifications first. Let me share some of the
doozies of the day.

Myth 1. "Undue focus on AIDS is weakening the struggle against
other killers of the poor." This will only be true if we design
silly AIDS programs. The fight against AIDS should be indissociable
from the fight against tuberculosis, for women's health and primary
health care (including vaccination campaigns), for primary
education, and, in short, for poverty reduction. Doing a good job
in AIDS prevention and care leads to a marked improvement in many
other health indices, as we've discovered in Haiti and in Rwanda,
where, unlike many NGOs or "faith-based organizations," we work
closely with the public health sector. ...

A related myth is this one: "Too much attention is paid to AIDS,
drawing attention away from chronic diseases, prevention efforts,
and primary health care." This is more of the same scrapping for
limited resources that underpinned the spurious
prevention-versus-care arguments. This endless debate, informed by
either-or logic and hangdog attitudes, has inflicted significant
damage in our line of work. In fact, we have shown in central
Haiti, in Rwanda, and elsewhere that when AIDS prevention and care
are planned properly they not only reinforce one another, but also
serve to improve the quality of health services in general. Also,
AIDS and tuberculosis are chronic diseases and, as far as I can
tell, ranking primary health care problems. Even malaria and its
attendant anemia are, in the end, chronic diseases. Putting in
place excellent and supervised treatment programs for these
diseases can improve the quality of care for any chronic disease
for which there is a deliverable, whether that deliverable be
insulin or anti-seizure medications.

An equally embarrassing argument is the one regarding the relative
importance of basic science research and interventions designed to
bring the fruits of such research to those in greatest need. Make
no mistake, this is a silly argument. The tools of modern medicine
come mostly from the lab, but we still need an "effector arm" to be
able to use these tools equitably. We need a malaria vaccine, safe
insecticides, and bednets; we need effective malaria treatment
programs, which sometimes includes a blood transfusion. These
cannot be either-or arguments.

The international health sector is, at the moment, balkanized and
squabbling because we've been starved of funds for so long we're
all competing with each other. But again, good programs to prevent
the transmission of HIV from mother to child will, if planned and
executed sensibly, improve women's health. And this does not occur
merely by giving out prenatal vitamins; it does occur if we
introduce modern obstetric care. ...the reason that AIDS and
maternal mortality are the leading causes of death is because both
are diseases of poverty. They affect the same group of women.
Focusing exclusively on either one of these ills means we don't
improve outcomes for the other.

Myth 2. "We lack the infrastructure to treat AIDS and other complex
diseases." This is not untrue, but misconceived. A lack of health
infrastructure is no reason for inaction but rather a clarion call
to action. We can build or rebuild infrastructures as we roll out
services; indeed, we need to do so. But the first steps can be
taken by capitalizing on the abundant human resources available in
places like Haiti and Rwanda. In our program, every patient has
...an outreach worker or accompagnateur - a neighbor who brings him
his medications every day. Some people think that we're training
outreach workers because they're all we've got, but this is not
true. It is true that when we first went to Rwanda earlier this
year, there were no physicians in the entire district to which we
were assigned by the Rwandan government. But we'd do it this way
even if there were plenty of doctors and nurses around. Treatment
that is supervised and community-based is simply better care for
chronic disease. This model of care, tuberculosis experts can tell
you, is the first line of defense against acquired resistance to
many antibiotics; it's probably even a good treatment model for
malaria, too, to round out the big three. In settings where
unemployment is high and these diseases are lethal, we've found no
shortage of people who would love to be accompagnateurs.

Training outreach workers is step one in a process that can lead to
improved health care infrastructure, as long as we devote adequate
resources to stocking and staffing clinics and hospitals serving
the poor, and as long as we stop asking cash-strapped countries to
further gut social services in the name of fiscal austerity. This
approach does not work in settings desperately in need of both
personnel and infrastructure and greater investments in public
health. The notorious "brain drain" will slow or be reversed if we
provide our African colleagues, for example, with the tools they
need to do their jobs properly and pay them a living wage - and a
living wage is surely even more important for outreach workers, who
live in poverty, than it is for physicians and nurses. ...

Many health programs have been encouraged by the bigger funders to
refrain from paying "community health volunteers." Volunteering
sounds OK, perhaps, until you ask: How can people who themselves
live in poverty be expected to work for free when people like me
are offered handsome stipends for consulting at every turn? It's
not always true that there's not enough money out there. Some
Americans would be surprised, I suspect, to learn where the money
goes. One commentary in the papers last month cited a study of U.S.
foreign aid spending written for Congress, concluding that "at
least 60 percent of U.S. foreign aid funding never leaves the U.S.,
but is instead spent on office overhead, travel, procurement of
American-made cars, computers, and other equipment, as well as
salary and benefit packages."6 While we're on this painful topic,
the idea that corruption is endemic in Africa and that this is a
good reason to freeze health programs is another canard. Corruption
occurs everywhere, as we've learned in contemplating some of the
industrial-strength corruption in my own country - and such
scandals have never yet led to calls for freezing public-health
expenditures on Wall Street or in Washington. In our own programs,
we've learned that poverty itself weakens the ability to provide a
transparent accounting of our work: how best do we do that when
there is no electricity, no computers, and when the bulk of the
world's accountants work for the rich instead of the poor?

Even this sort of grumpy analysis is cause for optimism because it
reminds us that, one, there are people out there who'd like to work
if only they can be paid enough to feed their families; and, two,
a lot of aid money never reaches its ostensible beneficiaries. And
if accountants can make fake energy companies look like something
other than a house of cards for quite a long while, they can surely
help health workers addressing the health crises of the poor learn
how better to manage long-overdue funds.

Myth 3. "People value health services more if they pay for them."
To my knowledge, there is no good data to support this oft-heard
claim - often heard, that is, among those who set policies or who
are not themselves in danger of dying simply because they cannot
pay a small user fee. Is there such a thing as a public good? Is
public health one of those public goods? Or should every single
health care service now become a commodity purchased in the market?
Some of our discussions of "cost-effectiveness" are really calls to
consecrate, as policy, a different standard of care for the
destitute. So far, PEPFAR and the Global Fund have declined to
lower the bar for AIDS care, and this is correct. Antiretroviral
therapy is the only way to treat advanced HIV disease. But the
architects of these funds should go a step further: they should
speak out against user fees for public health emergencies, and what
are AIDS, tuberculosis, malaria, and maternal mortality if not
public health emergencies? We will remain optimistic about our
ability to avert the majority of these deaths as long as folks in
Washington, London, Geneva, New York, Paris, Tokyo, or wherever,
would permit us to stop begging that some health services simply
must be seen as basic human rights.

And then there's the food fight... which is associated with all
sorts of myths and mystifications. The claim in question is that
money to prevent or treat AIDS shouldn't be used to pay for food or
school fees or water projects. Again, give us docs a hand here.
It's a basic fact of medicine that people dying of consumptive
diseases like AIDS or TB need not only the right drugs but also
lots of calories; they need clean water. And their families need to
eat and drink, too. International agricultural policies that even
doctors see as evidently unfair are not handed down on stone
tablets but created in meetings like this one. That means we can
change them, especially when we contemplate, on the same small
planet, an epidemic of obesity in one place and famine in another.
And we can use food aid a lot more wisely. Last month, Celia Dugger
of the New York Times wrote about a proposal now before the U.S.
Congress. The proposal would permit us to insist that our efforts
to feed the hungry not undermine the farmers who grow many of the
foodstuffs in Africa - the very people who are numbered, often
enough, among the hungry. There are obstacles to such sensible
policies and you might be surprised to learn how they are built up.
Dugger describes the "Iron Triangle of food aid," which includes
U.S. agribusiness, the shipping industry, and charitable
organizations, some of which, amazingly enough, make money by
selling food. "Given that at least 50 cents of each dollar's worth
of food aid is spent on transport, storage and administrative
costs, selling food to raise money in, say, Africa, is an
exceedingly inefficient way to finance long-term development,"
according to one expert who backed the proposal. "So why," asks
Dugger, "is this seemingly sensible, cost-effective proposal near
death in Congress? Fundamentally, because the proposal challenges
the political bargain that has formed the basis for food aid over
the past half century: that American generosity must be good not
just for the world's hungry but also for American agriculture."7
One major coalition of 16 non- profit groups joined in the
opposition to the proposal, but their opposition seems more related
to self- interest than to social justice.

School fees are also an AIDS-related issue. Poor kids in Africa and
in Haiti, kids we know personally, cannot pay them. Who is to
blame? Surely not their parents, some of them long dead of AIDS,
tuberculosis, or malaria. Who is responsible? Less than a month
ago, Human Rights Watch charged that "government neglect of
millions of children affected by HIV/AIDS is fueling school
drop-out across East and Southern Africa."8 But it wasn't African
governments that pushed austerity measures that weakened public
health and public education. It was the international financial
institutions, and they are us, here in this room.

The good news: if some years ago we gave bad advice in pushing
anti-poor policies - "structural adjustment programs" or food aid
that undermines hungry farmers - then it's not God or a natural
cataclysm that are to blame, it's us humans. And we can reverse our
advice and get kids back in school and make sure they have enough
to eat.

I've had 12 minutes to convince all of you that there is cause for
optimism in contemplating some grim numbers. Allow me to recap this
message in an upbeat manner. Look how much progress has been made
over the past couple of years. Only three years ago, someone like
me would have been invited to address you in the hopes of
persuading you that diseases like AIDS and drug-resistant
tuberculosis should be treated in what are termed "resource-poor
settings." Today, we spend less time prolonging that debate and
more time discussing how best to treat these diseases. We have
arguments about where to source our drugs, but that's a much better
debate, as far as patients and doctors are concerned, than arguing
about prevention versus treatment. Here are a few "take-home
messages," as they're termed in medical school:

AIDS prevention needs to occur in association with AIDS
treatment. The same can be said for all the other diseases of
poverty. Many complementary interventions are needed at once, and
they are urgent and feasible.

We cannot continue these funding catfights about treating AIDS
versus TB versus chronic diseases versus vaccination versus
whatever. We cannot argue about whether we should invest in science
or in care. We need everything. It's not that we're dealing only
with the "neglected diseases of poverty," but rather that poor
people's problems are neglected, period. This is true whether we're
discussing diabetes or tuberculosis, mental illness or AIDS; it's
true for women's health and for eyeglasses. We need tools that will
come only from basic science; we need to invest in health care
delivery. These are not zero-sum choices.

As with tuberculosis, supervised, community-based care is
probably the highest standard of care for AIDS. We call our
outreach workers accompagnateurs, but we don't care, frankly, what
they're called. They are the patients' advocates and the first line
of defense against acquired drug resistance, an inevitable
consequence of using antibiotics. Good, supervised care will slow
the acquisition of drug resistance; trying to keep medications from
the poor will not. And community-based care isn't some sort of
proprietary model, but one that we should adopt simply because it
works. In the poorer reaches of the world, I don't believe any
other model will be as effective.

Providers who work with the destitute sick need help with food,
school fees, clean water, and poverty alleviation in general. Doing
the right thing for people living in poverty and facing disease
will allow us to start a "virtuous social cycle," even if we began
by attacking AIDS, tuberculosis, malaria, or maternal mortality.

This is the world's great gamble.

We've cast the die, and created, at long last, institutions like
the Global Fund and programs like PEPFAR. Newly established
foundations have awakened to the world's health crises. Billions of
dollars will be invested in responding to epidemics that have spun
out of control. If we want these dollars to be invested wisely, we
have to link our projects to rebuilding health systems, to poverty
alleviation, and to food security - both at the level of individual
patients and their families and at the much more macro level. We
need to continue investing in basic science and product
development. With adequate resources and attention we can, I am
sure, manage to work on all of these levels at once.

So let's cheer up and get going.

Thank you.

AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
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